Transitional Care Manager RN Triage

Yale New Haven Health; New Haven (CT); Remote; USD 85,000 - 110,000; Full time

Job summary

The Transitional Care Manager Triage RN at Yale New Haven Health Services Corp. leads post-discharge triage, follow-up, and care coordination to reduce readmissions and ED visits.

This remote/onsite role collaborates with care teams to guide patients to appropriate levels of care and ensures timely follow-up. Responsibilities include post-hospital outreach, medication review, referral coordination, and EHR reporting, while maintaining confidentiality and adhering to quality standards; requires

Qualifications

• Bachelor's degree in a clinically related field and CT RN license.
• Minimum 3 years direct patient care and 2 years in case management in acute, community, or post-acute settings.
• Excellent communication, organizational skills, and ability to work independently; translation capability preferred.

Responsibilities

• Post-discharge calls and follow-up to reduce readmissions and ED visits; assess barriers and coordinate referrals.
• Collaborate with care management teams; coordinate equipment and services as directed.
• Perform telephonic triage and guide patients to appropriate level of care; maintain confidentiality.
• Generate and review EHR reports and ensure timely follow-up; adhere to quality standards.
• Travel to onsite locations as needed; support care navigation staff.

Skills

Motivational interviewing

Clinical judgment

Verbal and written communication

Organizational skills

Independent worker

Team collaboration

Translation capability

Basic computer skills

Education

Bachelor's degree in clinically related field

Job description

Overview

To be part of our organization, every employee should understand and share in the YNHHS Vision, support our Mission, and live our Values. These values - integrity, patient-centered, respect, accountability, and compassion - must guide what we do, as individuals and professionals, every day.

The Transitional Care Manager Triage RN is a member of the Enterprise Office of Population Health's Ambulatory Care Management team and is accountable for improving the health outcomes of the populations being managed. The TCM Triage Nurse provides clinical triage, post-discharge follow-up, and care coordination to support safe transitions of care and reduce avoidable Emergency Department visits and readmissions. This role uses evidence-based guidelines and strong communication skills to assess patient needs, manage symptoms, provide education, and escalat[e] care appropriately. The TCM Triage Nurse collaborates with providers, care management teams, and community resources to guide patients to the most appropriate level of care, address barriers to access, and ensure timely follow-up. Responsibilities include post-hospital and post-ED outreach, medication and discharge plan review, referral coordination, EHR documentation, report generation, and adherence to quality, productivity, and patient experience standards. The role requires independent clinical judgment, flexibility in managing priorities, strict confidentiality, and a commitment to service excellence. The TCM Triage Nurse also supports quality improvement efforts, maintains knowledge of community resources, and provides coaching and support to triage staff and Health Advisors as assigned. This role will work closely with RN Chronic Care Managers to enroll patients in Chronic Condition Management (CCM) if a patient is eligible and would benefit from the program.

EEO/AA/Disability/Veteran

Responsibilities

• 1.Performs post-hospital discharge and post-ED visit phone calls. Works to reduce the readmission and unnecessary Emergency Department visits by proactively identifying and addressing potential issues that could result in return to an acute setting. 1. As part of the interdisciplinary health care team, the Care Navigation nurse performs post-discharge follow up interviews, assesses existing barriers to health equity and assists with management of barriers or referrals to community resources including facilitation of transportation needs. 2. Engages patients and/or caregiver regarding care needs by validating awareness and understanding of post-acute discharge plan(s) including but not limited to review of discharge instructions, medications, and ensures scheduling and patient ability to attend follow-up appointments. 3. Facilitates appropriate routing or referrals and links patients to available resources and services needed, including use of connected services when appropriate 4. Generate and manipulate daily EHR reports to include various filters: i.e. discharge reports as recommended. 5. Guides patients to the most clinically appropriate and cost effective level of care to address their clinical issues. 6. Provides educational tools to patients and/or community services as requested. Educates patients and families on all components of a safe discharge, and best practices to avoid readmissions, manage disease states, and attain optimal wellness.
• 2.Demonstrates an ability to serve as a collaborative member of a multidisciplinary healthcare team. 1. Assists care management team to evaluate and redirect the current patient plan of care in order to streamline the delivery of service. 2. Contacts and coordinates with referral agencies to arrange provision of ordered equipment and associated services when appropriate and as directed by Care Management team. 3. Able to relate and communicate positively, effectively, and professionally with others; able to demonstrate positive customer service skills; work calmly and respond courteously when under pressure 4. Uses independent judgement prioritizes appropriately to ensure efficient utilization of time.
• 3.Demonstrates an understanding of clinical standards, quality performance goals and expected outcomes. 1. Demonstrates application of evidence-based practice and clinical practice guidelines to care plans and patient interventions. 2. Adheres to quality standards for care management per policy, including appropriate cases opened, comprehensive documentation, actionable care plans, and appropriate cases closed in a timely fashion. 3. Develops knowledge of population health, health equity, value-based care concepts and their application to the goals and objectives of the role and the department. 4. Demonstrates an understanding of managed care trends, payer regulations, reimbursement, and the effect of utilization on the different methods of reimbursement.
• 4.1.Performs telephonic triage to a diverse patient population using best practice clinical protocols and when indicated standing orders or use of referral trees to assist the patients to the appropriate level of care 2: Collaborates with wide array of healthcare clinicians and resources to secure time -sensitive response to patients with an objective of a one call resolution, when applicable 3: Follow up with patients providing test results, education, escalation or triage for medical management of symptoms when appropriate 4: Consistently demonstrate ability to respond to changing situations in a flexible manner to meet current needs, such as reprioritizing work as necessary. 5: Maintain strict patient confidentiality. Continuously expand knowledge and understanding of community resources while assisting patients to access and utilize available/appropriate resources available. Maintain working knowledge of regional community resources (Urgent Cares, Walk in Care, video Care, Emergency Departments, etc). 6:. Obtains all requested clinical documentation. Coaches, trains, and mentors new and existing triage staff. Provides routine feedback and oversight of Health Advisors.
• 5.Performs other duties as requested or required

Qualifications

EDUCATION

Bachelors degree in clinically related field. R.N. license required.

EXPERIENCE

Minimum of 3 years of clinical experience in direct patient care, 2 years of case management experience in an acute, community, or post-acute provider or health plan.

LICENSURE

RN Licensure in Connecticut

SPECIAL SKILLS

- Motivational interviewing skills necessary. - Receptivity to working in an iterative care environment based upon evolving patient and institutional needs - Excellent verbal and written communication skills. - Possesses excellent organizational skills and ability to handle multiple priorities. - Ability to work in an independent role with minimal supervision. - Functions as an integral team member and demonstrates flexibility in sharing responsibilities. - Validated translation capability preferred. - Working knowledge of computers and basic software applications used in job functions, such as word processing, databases, spreadsheets, and others as needed.

PHYSICAL DEMAND

-Role is primarily a remote work position with the ability and expectation to travel to onsite practice locations from time to time as requested by management. Ability to attend initial onsite orientation and onboarding program as well as monthly onsite training obligations. Adheres to all organizational remote worksite standards. Outreach performed 7 days a week and requires weekend and some holiday staffing.

YNHHS Requisition ID

197581